Patient Birth Date / / Approx Weight SYSTEMS SURVEY FORM Doctor INSTRUCTIONS: Fill in only the circles which apply to you. Leave blank if you don't have the problem. Fill in the circle marked 1 for MILD symptoms (occurs rarely). Fill in the circle marked 2 for MODERATE symptoms (occurs several times a month). Fill in the circle marked 3 for SEVERE symptoms (occurs almost constantly). Leave circles BLANK if they don't apply to you! Date Vegetarian Gluten-free GROUP 1 1 Acid foods upset 8 Unable to relax; startles easily 15 2 Get chilled often 9 Extremities cold, clammy 16 3 "Lump" in throat 10 Strong light irritates 17 4 Dry mouth-eyes-nose 11 Occasionally weak urine flow 18 5 Pulse speeds after meal 12 Heart pounds after retiring 19 6 Keyed up - fail to calm 13 "Nervous" stomach 7 Gag occasionally 14 Appetite reduced occasionally Cold sweats often Get heated easily Nerve discomfort Staring, blinks little Sour stomach frequent 20 21 22 23 24 25 26 27 GROUP 2 Joint stiffness on arising 28 Digestion rapid 36 Muscle-leg-toe cramps at night 29 Vomiting occasionally 37 "Butterfly" stomach, cramps 30 Hoarseness frequent 38 Eyes or nose watery 31 Uneven breathing 39 Eyes blink often 32 Pulse slow 40 Eyelids swollen, puffy 33 Gagging reflex slow Indigestion soon after meals 34 Difficulty swallowing Always seems hungry; feels 35 Temporary constipation or "lightheaded" often diarrhea "Slow starter" Get "chilled" Perspire easily Sensitive to cold Upper respiratory challenges 41 42 43 44 45 46 47 Eat when nervous Excessive appetite Hungry between meals Irritable before meals Get "shaky" if hungry Fatigue, eating relieves "Lightheaded" if meals delayed 48 49 50 51 GROUP 3 Heart palpitates if meals missed or delayed Fatigue in afternoons Overeating sweets upsets Awaken after few hours sleep - hard to get back to sleep 52 53 54 Crave candy or coffee in afternoons Moods of blues or melancholy Craving for sweets or snacks 55 56 57 58 59 60 61 Hands and feet go to sleep 62 easily, numbness 63 Sigh frequently, "air hunger" 64 Aware of "breathing heavily" High altitude discomfort 65 Opens windows in closed rooms 66 Immune system challenges Afternoon "yawner" GROUP 4 Get "drowsy" often Swollen ankles, worse at night Muscle cramps, worse during exercise; get "charley horses" Difficulty catching breath especially during exercise Tightness or pressure in chest, worse on exertion 67 68 69 70 Skin discolors easily after impact Tendency to anemia Noises in head, or "ringing in ears" Fatigue upon exertion
SYSTEMS SURVEY FORM - PAGE 2 GROUP 5 71 Dizziness 80 Worrier, feels insecure 88 72 73 Dry skin Burning feet 81 Nausea occasionally after eating 89 74 Blurred vision 82 Greasy foods upset 90 75 Itching skin and feet 83 Stools light colored 91 76 Hair loss 84 Skin peels on foot soles 92 77 Occasional skin rashes 85 Discomfort between shoulder 93 78 Bitter, metallic taste in mouth blades 94 in mornings 86 Occasional laxative use 79 Occasional constipation 87 Stools alternate from soft to watery 95 96 97 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 GROUP 6 Loss of taste for meat 98 Coated tongue 101 Lower bowel gas several hours 99 Pass large amounts of 102 after eating 104 105 106 107 108 109 110 111 112 113 114 Burning stomach sensations, eating relieves (A) Difficulty sleeping On edge Can't gain weight Intolerance to heat Highly emotional Flush easily Night sweats Thin, moist skin Inward trembling Heart races Increased appetite without weight gain Pulse fast at rest Eyelids and face twitch Irritable and restless Can't work under pressure (B) Increase in weight Decrease in appetite Fatigue easily Ringing in ears Sleepy during day Sensitive to cold Dry or scaly skin Temporary constipation Mental sluggishness Hair coarse, falls out Tension in head upon arising wears off during day Slow pulse, below 65 Changing urinary function Sounds appear diminished Reduced initiative 100 134 135 136 137 138 139 140 141 142 143 144 foul-smelling gas 103 Indigestion 1/2-1 hour after eating; may be up to 3-4 hours after (C) GROUP 7 Failing memory with age Increased sex drive Episodes of tension in head Decreased sugar tolerance (D) Abnormal thirst Bloating of abdomen Weight gain around hips or waist Sex drive reduced or lacking Tendency for stomach issues Increased sugar tolerance Menstrual disorders 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 Sneezing attacks Dreaming, nightmare type bad dreams Bad breath (halitosis) Milk products cause upset Sensitive to hot weather Burning or itching anus Crave sweets Watery or loose stool Gas shortly after eating Stomach "bloating" (E) Dizziness Headaches Hot flashes Hair growth on face or body (female) Sugar in urine (not diabetes) Masculine tendencies (female) (F) Weakness, dizziness Tired throughout day Nails weak, ridged Sensitive skin Stiff joints Perspiration increase Bowel discomfort Poor circulation Swollen ankles Crave salt Areas of skin darkening Upper respiratory sensitivity Tiredness Breathing challenges
SYSTEMS SURVEY FORM - PAGE 3 165 166 167 168 169 170 171 172 173 174 GROUP 8 Muscle weakness 175 Tendency to consume sweets 184 Lack of Stamina or carbohydrates Drowsiness after eating 176 Muscle spasms 185 Muscular soreness 177 Blurred vision 186 Heart races 178 Involuntary muscle action Hyper-irritable 179 Numbness 187 Feeling of a band around your 180 Night sweats head 181 Rapid digestion 188 Melancholia (feeling of 182 Sensitivity to noise 189 sadness) 183 Redness of palms of hands and 190 Swelling of ankles bottom of feet 191 Change in urinary function Visible veins on chest and abdomen Hemorrhoids Apprehension (feeling that something bad will happen) Nervousness causing loss of appetite Nervousness with indigestion Gastritis Forgetfulness Thinning hair 192 193 194 195 196 1. 2. 3. FEMALE ONLY Very easily fatigued 197 Menstruate too frequently 202 Premenstrual tension Menses more painful than usual 198 Hysterectomy / ovaries removed 203 Depressed feelings before menstruation 199 200 Menopausal hot flashes Menses scanty or missed 204 Painful breasts during 201 Acne, worse at menses 205 menses IMPORTANT Please list the five main complaints you have in the order of their importance: 206 207 208 209 210 211 212 MALE ONLY Less involved in exercise/social activities Difficult to postpone urination Weak urinary stream Feeling of blues or melancholy Feeling of incomplete bowel evacuation Lack of energy Muscles in arms and legs seem softer/smaller Tire too easily Avoids activity Leg nervousness at night Diminished sex drive 203 4. 5. BARNES THYROID TEST This test was developed by Dr. Broda Barnes, M.D. and is a measurement of the underarm temperature to determine hypo and hyperthyroid states. The test is conducted by the patient in the a.m. before leaving bed - with the temperature being taken for 10 minutes. The test is invalidated if the patient expends any energy prior to taking the test - getting up for any reason, shaking down the thermometer, etc. It is important that the test be conducted for exactly 10 minutes, making the prior positioning of both the thermometer and a clock important. PRE-MENSES FEMALES AND MENOPAUSAL FEMALES Any two days during the month FEMALES HAVING MENSTRUAL CYCLES The 2nd and 3rd day of flow OR any 5 days in a row MALES Any 2 days during the month RESTRICTIONS ON USE THE SYSTEMS SURVEY IS TO BE USED ONLY BY TRAINED HEALTH CARE PRACTITIONERS. IF YOU ARE A PATIENT, YOU SHOULD NOT USE THE SYSTEMS SURVEY. IF YOU ARE NOT A TRAINED HEALTH CARE PRACTITIONER, YOU SHOULD NOT USE THE SYSTEMS SURVEY. HEALTH CARE PRACTITIONERS SHOULD ONLY USE THE SYSTEMS SURVEY TO PROVIDE SERVICES THAT ARE WITHIN THE SCOPE OF THEIR LICENSE OR PROFESSIONAL TRAINING. THE SYSTEMS SURVEY IS NOT INTENDED TO DIAGNOSE ANY DISEASE. THE SYSTEMS SURVEY IS INTENDED TO BE USED AS A HELPFUL TOOL FOR HEALTH CARE PRACTITIONERS IN COLLECTING INFORMATION CONCERNING THE HEALTH AND WELLNESS OF PATIENTS.
SYSTEMS SURVEY FORM - PAGE 4 Please list any medications you are taking: No Medications Please list any vitamins, herbs, or supplements you are taking: No Vitamins Please list any allergies you have: No Allergies Please list any surgeries you have had in the past 12 months: No Recent Surgeries Please list any other surgeries or medical procedures you have had: No Other Surgeries TO BE COMPLETED BY DOCTOR Blood Pressure: Recumbent Pulse: Recumbent Standing Standing Hema-Combistix Urine Readings: ph Albumin % Glucose % Occult Blood ph of Saliva ph of Stool Specimen Blood Clotting Time Hemoglobin Blood Type Weight
SYSTEMS SURVEY FORM - PAGE 5 Use the letters listed below to indicate the type and location of your pain and sensations: KEY A = ACHE B = BURNING S = STABBING N = NUMBNESS P = PINS & NEEDLES O = OTHER PLEASE INDICATE THE LEVEL OF PAIN YOU ARE EXPERIENCING NO PAIN SEVERE PAIN 0 4 5 6 7 8 9 10 Patient Signature Date